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  ========================LICENSE_START=================================
  screenit-web
  %%
  Copyright (C) 2012 - 2020 Facilitaire Samenwerking Bevolkingsonderzoek
  %%
  This program is free software: you can redistribute it and/or modify
  it under the terms of the GNU Affero General Public License as published by
  the Free Software Foundation, either version 3 of the License, or
  (at your option) any later version.
  
  This program is distributed in the hope that it will be useful,
  but WITHOUT ANY WARRANTY; without even the implied warranty of
  MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE.  See the
  GNU General Public License for more details.
  
  You should have received a copy of the GNU Affero General Public License
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  =========================LICENSE_END==================================
  -->
<html xmlns:wicket="http://wicket.apache.org" xmlns="http://www.w3.org/1999/html">
<wicket:extend>
    <div class="row-fluid">
        <div class="span12">
            <h1 class="pageTitle">Betalingen huisarts</h1>
        </div>
    </div>
    <fieldset>
        <div class="row-fluid form-horizontal">

            <wicket:container wicket:id="paspoort"></wicket:container>
            <div class="row-fluid form-horizontal">
                <div class="span9">
                    <fieldset>
                        <form wicket:id="verrichtingZoekenForm">
                            <div class="row-fluid">
                                <div class="span6">
                                    <div class="control-group">
                                        <label for="screeningOrganisatie" class="control-label">Screeningsorganisatie</label>
                                        <div class="controls">
                                            <select id="screeningOrganisatie" wicket:id="screeningOrganisatie" class="form-control"></select>
                                            <span wicket:id="soLabel"></span>
                                        </div>
                                    </div>
                                    <div class="control-group">
                                        <label for="huisartsLocatie" class="control-label">Locatie:</label>

                                        <div class="controls">
                                            <select id="huisartsLocatie" wicket:id="huisartsLocatie" class="form-control"></select>
                                        </div>
                                    </div>
                                    <div class="control-group">
                                        <label class="control-label">Monster-id</label>
                                        <div class="controls">
                                            <input wicket:id="monsterId" type="text">
                                        </div>
                                    </div>
                                    <div class="control-group">
                                        <label class="control-label">Geboortedatum</label>
                                        <div class="controls">
                                            <div class="input-append">
                                                <input wicket:id="geboorteDatum" type="text" placeholder="dd-mm-jjjj" size="16" class="input-small three-months">
                                                <a href="javascript:void(0);" class="btn" onclick="$(this).prev().datepicker('show');return false;" title="DatumGebdatum"><i class="icon-calendar"></i></a>
                                            </div>
                                        </div>
                                    </div>
                                    <div class="control-group">
                                        <label class="control-label">BSN</label>
                                        <div class="controls">
                                            <input wicket:id="bsn" type="text">
                                        </div>
                                    </div>
                                </div>
                                <div class="span6">
                                    <div class="control-group">
                                        <label class="control-label">Verrichtingsdatum vanaf</label>
                                        <div class="controls">
                                            <div class="input-append">
                                                <input wicket:id="verrichtingsDatumVanaf" type="text" placeholder="dd-mm-jjjj" size="16" class="input-small three-months">
                                                <a href="javascript:void(0);" class="btn" onclick="$(this).prev().datepicker('show');return false;" title="DatumVanaf"><i class="icon-calendar"></i></a>
                                            </div>
                                        </div>
                                    </div>
                                    <div class="control-group">
                                        <label class="control-label">Verrichtingsdatum t/m </label>
                                        <div class="controls">
                                            <div class="input-append">
                                                <input wicket:id="verrichtingsDatumTotenmet" type="text" placeholder="dd-mm-jjjj" size="16" class="input-small three-months">
                                                <a href="javascript:void(0);" class="btn" onclick="$(this).prev().datepicker('show');return false;" title="DatumTotenmet"><i class="icon-calendar"></i></a>
                                            </div>
                                        </div>
                                    </div>

                                    <div class="control-group">
                                        <label class="control-label">Datum uitstrijkje </label>
                                        <div class="controls">
                                            <div class="input-append">
                                                <input wicket:id="datumUitstrijkje" type="text" placeholder="dd-mm-jjjj" size="16" class="input-small three-months">
                                                <a href="javascript:void(0);" class="btn" onclick="$(this).prev().datepicker('show');return false;" title="DatumUitstrijkje"><i class="icon-calendar"></i></a>
                                            </div>
                                        </div>
                                    </div>

                                    <div class="control-group">
                                        <label class="control-label">Betalingskenmerk</label>
                                        <div class="controls">
                                            <input wicket:id="betalingskenmerk"
                                                   class="BSNInput" type="text">
                                        </div>
                                    </div>
                                    <div class="control-group">
                                        <label class="control-label"> &nbsp;</label>
                                        <div class="controls">
                                            <label class="checkbox inline">
                                                <input wicket:id="alleenZonderBetalingskenmerk" type="checkbox"> Alleen regels
                                                zonder betalingskenmerk
                                            </label>
                                        </div>
                                    </div>
                                    <button wicket:id="filteren" class="btn btn-primary right zoekBtn">Filteren</button>
                                </div>
                            </div>
                        </form>
                    </fieldset>
                </div>
                <div wicket:id="totalenContainer" class="span3">
                    <fieldset class="hero-unit">
                        <div class="row-fluid">
                            <div class="span12">
                                <legend>
                                    <span class="clearfix"><strong>Totalen</strong></span>
                                </legend>
                            </div>
                        </div>
                        <div class="row-fluid">
                            Aantal uitstrijkjes: <strong wicket:id="aantalUitstrijkjes">-</strong>
                        </div>
                        <div class="row-fluid">
                            Totaal bedrag: <strong><span wicket:id="totaalBedrag">0,00</span></strong>
                        </div>
                    </fieldset>
                </div>
            </div>
            <div class="row-fluid form-horizontal">
                <div class="span12">
                    <fieldset>
                        <div wicket:id="verrichtingenTableContainer" class="row-fluid">
                            <div class="span12">
                                <div wicket:id="exporteren" class="dropdown right">
                                    Exporteren
                                </div>
                                <br/><br/>
                                <div wicket:id="huisartsVerrichtingenTabel" class="table table-bordered table-condensed">
                                    <thead>
                                    <tr>
                                        <th><a href="javascript:;">Screeningsorganisatie</a></th>
                                        <th><a href="javascript:;">Naam cliënt</a></th>
                                        <th><a href="javascript:;">Geboortedatum</a></th>
                                        <th><a href="javascript:;">BSN</a></th>
                                        <th><a href="javascript:;">Monster-id</a></th>
                                        <th><a href="javascript:;">Verrichtingsdatum</a></th>
                                        <th><a href="javascript:;">Datum uitstrijkje</a></th>
                                        <th><a href="javascript:;">Ontvangst formulier</a></th>
                                        <th><a href="javascript:;">Bedrag</a></th>
                                        <th><a href="javascript:;">Betalingskenmerk</a></th>
                                    </tr>
                                    </thead>
                                    <tbody>
                                    <tr>
                                        <td>Bevolkingsonderzoek Noord</td>
                                        <td>J. Doe</td>
                                        <td>01-01-1985</td>
                                        <td>111222333</td>
                                        <td>951357852456</td>
                                        <td>Primair uitstrijkje op HPV geanalyseerd</td>
                                        <td>01-03-2015</td>
                                        <td>01-03-2015</td>
                                        <td>01-03-2015</td>
                                        <td>€ 0,00</td>
                                        <td>1234</td>
                                    </tr>
                                    </tbody>

                                </div>
                            </div>
                        </div>

                    </fieldset>
                </div>
            </div>
        </div>
    </fieldset>
</wicket:extend>
</html>
